The document discusses the pelvic floor muscles and their dysfunctions. It describes the anatomy of the pelvis including bones, ligaments, and muscles like the levator ani. Dysfunctions of the pelvic floor muscles can cause urinary incontinence, fecal incontinence, and pelvic organ prolapse. Non-surgical and surgical treatment options are presented for each condition. Evaluation methods like pad tests and POPQ classification are also covered.

1. Pelvic floor muscles and
it’s dysfunction!!
Dr. Dhwani kawedia
pelvic floor muscle and it's dysfunction 1

2. pelvic floor muscle and it's dysfunction 2
Pelvis is formed by:4 bone and 4 joints:
• right hip bone
• Left hip bone
• Sacrum
• Coccyx
• Pubic symphysis
• Left and right Sacro iliac joint
• Sacrococcygeal joint

3. pelvic floor muscle and it's dysfunction 3
Ligaments and membranes:
Obturator membrane
Sacrotuberous
ligament

4. pelvic floor muscle and it's dysfunction 4
Muscles :
It forms the posterior
wall, also helps in filling
the gap of greater sciatic
foramen
Greater
sciatic
foramen

5. pelvic floor muscle and it's dysfunction 5
Lesser pelvis/true pelvis : pelvic walls
Bony walls:
Anteriorly:
Pubis symphysis
Posteriorly :
Sacrum and coccyx
Rami of ischium
pubic rami

6. pelvic floor muscle and it's dysfunction 6
Pelvis muscle
Piriformis &
Obturator
internus(lateral
rotators of hip
joint)
Levator ani &
Coccygeus(pelvic
diaphgram )
2 levator ani and
coccygeus muscle
forming a diaphgram
& it seprates pelvis
from perinium
pubococcygeus
iliococcygeus
Ischiococcygeus/
coccygeus
Nerve supply:
A branch from 4th scaral
nerve .
A branch from inferior
rectal nerve.
Nerve supply:
S4 & S5

7. pelvic floor muscle and it's dysfunction 7
Pubococcygeus
Illiococcygeus
Ishiococcygeus
Anterior fibers
Middle
fibers/puborectalis
Posterior
Fibers
Ischiococcygeus/
coccygeus :
Partly muscular
and partly
tendinosis.

8. pelvic floor muscle and it's dysfunction 8
Actions : levator ani:
Counteract or resist
increased intra abdominal
pressure and help to
maintain continence of
the bladder and rectum
Micturition, parturition, defecation Pelvic outlet is open
Contraction of fibers resist intra abdominal
pressure and prevents further prolapse

9. pelvic floor muscle and it's dysfunction 9
Urinary
incontinence
(stress, urge and
mixed
incontinence)
Pelvic
floor
dysfunction
Faecal
Incont
-inence
Pelvic
organ
prolapse

10. pelvic floor muscle and it's dysfunction 10
URINARY INCONTINENCE

11. pelvic floor muscle and it's dysfunction 11

12. pelvic floor muscle and it's dysfunction 12

13. pelvic floor muscle and it's dysfunction 13
If Sphincter
Damaged(Outlet incompetence )
They cant stop urine
from leaking out
Caused by:
Utheral hypermobility
Intrinsic sphincter
deficienct
Uthera cant be still
becoz muscle
surrounding it are
very weak.
e.g. vaginal deleviery
Damage to
sphincter muscles
e.g. complication
of prostate
surgery

14. pelvic floor muscle and it's dysfunction 14
Sudden urge to urinate.
Involuntary urination
(unhibited detrusor
muscle ) Associated with
Urinary tract infection

15. pelvic floor muscle and it's dysfunction 15
Combination of both stress &
urgency incontinence
+
Urinary tract
infection

16. pelvic floor muscle and it's dysfunction 16
 Incomplete emptying of bladder
 Bladder fills up
 Overflow with urine :
Blockage in urine flow
outlet obstruction
Ineffective detrusor muscle
diabetes(polyuria)
neurogenic bladder(multiple sclosis)

17. pelvic floor muscle and it's dysfunction 17
 Post-void residual urine test
<50 mL –normal
In adult/patient with
UTI -50mL – 100mL
(Normal)
>50mL/200mL -
abnormal
 Pad test

18. pelvic floor muscle and it's dysfunction 18
Bladder
training
Pelvic
floor
muscle
exercises
Biofeedback
Electric
stimulati
on
Vaginal
and
urethral
tools
Medicinal
therapy
Acupuncture
Non
surgical
treatment
options

19. pelvic floor muscle and it's dysfunction
19
Colposuspension
Sling surgery
Urethral bulking agents

20. pelvic floor muscle and it's dysfunction 20
Artificial urinary sphincter

21. pelvic floor muscle and it's dysfunction 21
Sacral nerve/posterior tibial nerve stimulation

22. pelvic floor muscle and it's dysfunction 22
Urinary diversion

23. pelvic floor muscle and it's dysfunction 23
Fecal incontinence is the loss
of control over bowel
movements, resulting in the
leakage of gas or stool
(feces) through the anus
puborectalis muscle,
internal anal sphincter
muscle,
external anal sphincter
muscle

24. pelvic floor muscle and it's dysfunction 24

25. pelvic floor muscle and it's dysfunction 25
Causes
Damage to
the muscles
Damage to
the nerves
Rectocele
Loose stool
Loss of
storage
capacity in
rectum

26. pelvic floor muscle and it's dysfunction 26
the external anal sphincter is under voluntary
control.
The internal anal sphincter provides 70% of the
resting tone of the anal canal
Puborectalis muscle- the anorectal angle 90° (rest)
Angle >90° (during defecation attempts)

27. pelvic floor muscle and it's dysfunction 27

28. pelvic floor muscle and it's dysfunction 28
sphincteroplasty
inflatable artificial sphincter
colostomy

29. pelvic floor muscle and it's dysfunction 29
Anal
Sphincter
exercise:
It takes time for exercise to make muscle stronger. You may need to exercise regularly for
several months before the muscles gain their full strength.
As the muscles get stronger, you will find that you can hold for longer than five seconds, and
that you can do more pull-ups each time without the muscle getting tired.
Try for five quick pull-ups.
Pull up the muscles as quickly and tightly as you can and then relax and then pull up again, and
see how many times you can do this before you get tired.
Repeat twice. This will work on the endurance or staying power of your muscles.
Next, pull the muscles up to about half of their maximum squeeze. See how long you can hold
this for. Then relax for at least 10 seconds.
Hold tightened for at least five seconds, then relax for about 4 seconds. Repeat five times. This
will work on the strength of your muscles.
Tighten and pull up the sphincter muscles as tightly as you can.
Sit, stand or lie with your knees slightly apart.

30. pelvic floor muscle and it's dysfunction 30
Pelvic organ prolapse
Prolapse might include (top to
bottom):
bladder (cystocele),
vagina (enterocele),
rectum (rectocele).
Colour codes include purple
(bladder), orange (vagina),
brown (colon and rectum), and
green (peritoneum)

31. pelvic floor muscle and it's dysfunction 31
Supports:
Muscular supports: levator ani:
pubococcygeus
Illiococcygeus
Supplied by: pudendal n.(if it get damaged can lead to weakening of pelvic diphgram causing pelvic organ
prolapse )
Urogenital diaphragm
-Deep transverse perianal
-Ext. urethral sphincter
-Superior fascia
-Inferior fascia(perineal pouch)
Deep perineal pouch

32. pelvic floor muscle and it's dysfunction 32
Muscles supporting uterus & vagina
Bulbospongiosus muscle
Levator ani
Ext. urethral sphincter
Superficial transverse perineal
Deep transverse perineal
Mechanical support:
 Angle of anti-version(90)
 Angle of anti-flexion(120)
Ligament support:
 Uterosacral ligament
 Mackenrodt ligament
 Pubocervical ligament
 Round ligament(secondary
support-prevents antiflexion)

33. pelvic floor muscle and it's dysfunction 33
Uterosacral ligament
Transverse ligament
Mackenrodt ligament
Cardinal ligament
Pubocervical lifament

34. pelvic floor muscle and it's dysfunction 34
Risk
factor
Traumatic
Deliveries
(birth
trauma)
Repeated
childbirth
(multiparity)
Precipitate
Labor
Prolonged
labor
Ehlers
danlos
syndrome
(CTD)
Marphan
Syndrome
(CTD)
Heavy
weight
lifting after
delivery
Condition
with
increased
intra
abdominal
pressure
Spina
bifida
Menopause
Faulty instrument
Pundenal nerve
damage
Ligamenteous
tear

35. pelvic floor muscle and it's dysfunction 35
Patient feels something is coming out of vagina.
Groin/back pain (stretching of uterosacral ligament).
Difficulty in urinating & defacting.
increased risk of uti.
Decubitus ulcer (venous congestion)

36. pelvic floor muscle and it's dysfunction 36
POPQ
classification
(hymen)
Baden walker
half way
classification
Shaw's
classification

37. pelvic floor muscle and it's dysfunction 37
Vaginal prolapse :
Anterior vaginal wall-
Upper 2/3-cyctocele
Lower 1/3-utherocele
Posterior vaginal wall-
Upper 1/3-entrocele
Middle 1/3-retocele
Lower 1/3-lax perenium

38. pelvic floor muscle and it's dysfunction 38

39. pelvic floor muscle and it's dysfunction 39
Congenital prolapse / young female
Desiring for future pregnancy
Mx-sling surgery(Mersilene tape )/cervicopexy
Sling surgery- purandre sling (resctus fascia)
Khanna sling (ASIS)
shirodkar sling (more
complication)
Female with no desire of future child bearing
but want to continue menstrual cycle
Mx- fothergills/Manchester surgery
Steps:
Cervical amputation
Plication of cardinal ligament
*Only plication will prevent 2nd trimenster
abortion or cervical stenosis(modification of
forthergills surgery)

40. pelvic floor muscle and it's dysfunction 40
Female doesn't want pregnancy/mensuration
Mx- vaginal hysterectomy + pelvic floor
repair + sacrospinous colpopexy
Female having contraindication for surgery/refusing
Mx- ring pessary
Female≥ 65 yrs
Mx- leforts colpoclesis (vaginal closure)
Scrapping
of vagina
(forming
adhesions)

41. pelvic floor muscle and it's dysfunction 41
Vault prolapse
Mx- vault suspension surgery
Mesh sacral colpopexy
Uterosacral suspension
Sacrospinous fixation

42. pelvic floor muscle and it's dysfunction 42
Physical therapists play a major role in the nonsurgical management of POP. Along with pessary support, pelvic-
floor muscle training (PFMT) is cited in highly credible reviews as a main nonsurgical option for women with POP.
https://kathewallace.com/wp-content/uploads/2020/05/P-QOL.pdf

43. pelvic floor muscle and it's dysfunction 43
Take home message:
 When biofeedback is used in combination with electric stimulation,
significant increase in pelvic floor strength and reduction in severity of
incontinence have been reported. In urinary incontinence treatment, electric
stimulation can be applied for 6-8 weeks in sessions of 20-30 minutes 3 times
a week.
 Pad test > 1g is significant

44. pelvic floor muscle and it's dysfunction 44
References :
 DC Dutta'ss Textbook of Gynecology
 Kari_Bo,_Bary_Berghmans,_Siv_Morkved,_Marijke_Van_Kampen_Evidence
 Volume 2, BD Chaurasia’s Human Anatomy, Lower Limb, Abdomen and Pelvis
 https://www.yourpelvicfloor.org/conditions/fecal-incontinence/
 https://www.anadolumedicalcenter.com/en/health-technologies/urine-
kidnappingumeda-biofeedback
 https://www.nhs.uk/conditions/urinary-incontinence/surgery/
 https://www.stmarkshospital.nhs.uk/wp-content/uploads/2014/05/Anal-
sphincter-exercises-for-leakage.pdf
 https://www.med.umich.edu/1libr/Gyn/AnalSphincteroplasty.pdf